'Borderline' is Code for 'Difficult' is the title of an article by Bruce Bower in Science News. The article reports on a major challenge faced by women, and men as well, who suffer from borderline personality disorder and the relationship struggles that syndrome tends to bring. The article quotes Sandra Sulzer of the University of North Carolina at Chapel Hill who conducted extensive interviews with psychologists and psychiatrists. Her research clarified that the diagnosis of borderline, for all too many therapists, connotes needy, manipulative people, drama queens who do not need or benefit from treatment. "Clinicians," Sulzer said, "frequently view borderline personality disorder symptoms as signs of badness, not sickness..."

The attitude toward borderline personalilty disorder that equates borderline with difficult merits challenging. This blogpost is the first in a series of posts that aim to offer an alternative, more empathic, view.

The seeds of this post were planted by a reader who wrote an email to me complaining of what she had interpreted in my earlier blogposts on this syndrome as a perjoritive attitude toward folks with bpd. H.O.'s apparently knowledgable perspective piqued my interest.

So I wrote back. And H.O. responded further.

The resulting informative dialogue about borderline personalilty disorder has influenced me greatly. I am pleased therefore to be able, having received H.O.'s permission, to share our dialogue with PsychologyToday.com readers.

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Dear Dr. Heitler,

People with BPD don't want to be treated like royalty. They just want to be loved, an emotion which many never experienced. There is stong biological vulnerability and often horrific abuse which results in this devastating condition. For BPD sufferers. dysphoria, or mental pain, is their baseline mood, which can feel unbearable. Their lives are hellish.

As a physician who has worked with borderline personality disorder patients herself, and a BPD sufferer personally, I really appreciate your interest.

As a borderline personality disorder sufferer myself I want you to know that we are not manipulative. We are desperate.

We don't know how to live with others, how to have friends and get our needs met the normal way. We simply are ignorant in this respect.

If you read Freud's classic works he points out that intense feelings bring about "abaissement de niveau mentale" which means it clouds judgement to the point of insanity. Our uncontrollable and horrible emotions deprive us of ability to think and control our behaviour. Our behaviours are not meant to harm, at least not mine. Rather they are an expression of desperation.

We do not manipulate by cutting ourselves. We cut because pain of being borderline is so intense and so unbearable that the little kick of endogenous endorphins in reaction to acute physical pain is the only thing that brings relief from this horrific mental pain. How bad would you have to feel to want to kill yourself? We feel like it most of the time.

Please understand. Having a borderline personality disorder means suffering which I can only compare to terminal cancer.

If you saw a cancer patient howling with pain you would have compassion. The world does not have compassion toward us, even though we howl with pain, because our effort to escape unbearable pain cause behaviours which antagonize people.

Please believe me, if our pain went away we would not do any of the 'bad' things that the world finds inappropriate or harmful. We commit suicide because our pain is sometimes simply impossible to bear.

Please believe me, the depression and dysphoria of BPD is the most horrible feeling. Sometimes I prefer I had cancer instead. At least then the whole world would not blame me for desperate efforts to blunt the pain brought about by my biological vulnerability and abuse I suffered as a child.

Pain is the core and the essence of borderline personality disorder.

BPD behaviours are nothing but inefficient ways to escape the pain. It is a vicious circle because these behaviours bring even more pain.

Pain distorts reality and results in what traditionally was called "borderline" psychosis. Our perception of reality is so distorted by intense emotion that we do not think straight. Only after recovery do we realize how we were wrong and how our perceptions were distorted by the illness.

When symptomatic, a Borderline is in living hell, surrounded by perceived universal hostility.

I wish you all the best in your efforts to help alleviate this horrible condition and damage it brings both to the sufferers and those who have to deal with them.

With regards,

H. O.

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Response from Dr. Heitler

Thank you so much H.O. for this description of your experience as someone who suffers from Borderline Personality Disorder. What you describe fits very much with newer theories that bpd is at core a function of amgydala hyper-reactivity.

The amygdala is the part of the brain that tells us when there is a danger ahead. A hyper-reactive amygdala sees danger where there is none and reads small dangers as catastrophic.

These overly intense emotional reactions cause the thinking parts of the brain to turn off and the ability to take in new non-confirmatory information to drop down to near zero, both of which add to the difficulties of self-soothing.

More on this disorder and potential helpful treatments to follow...

dr h

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FURTHER READING ON THIS TOPIC

Dr. Heitler's articles on this blog on the subject of borderline personality disorder include:

Denver clinical psychologist Susan Heitler, Ph.D, a graduate of Harvard and NYU, is author of Power of Two, a book,workbook, and website that teach the communication skills that save and sustain positive relationships.

Warmest thanks for sharing with us (H.O. and myself) your appreciation of this article. H.O. totally seemed to me to, as you say, "know what she is talking about." I am very pleased to hear validation as well from a "fellow bpd sufferer."

You could have just responded, "Actually I don't have BPD, the person corresponding with me does. I'm so glad this article validated your feelings".
Seriously, that would have been so much easier than putting "know what she is talking about" and "fellow bpd sufferer" in quotations as an ineffective atempt at saying the same thing.
Tiptoeing around people and walking on eggshells in this way is offensive, it implies that the hearer is too stupid, too mentally ill, or too personality disordered to have a simple error politely pointed out.

I grew up with a BPD it was a living hell, reading this article just further convinces me that there is no cure. My brother caused pain and suffering to our parents, me, our pets and still to this day feels he was the victim ... much like the writer of this article. Heaven help those who cross or attempt to treat these people ... you will never cure them....Self serving and unable to relate to others they want an audience! I disengaged myself and my family from my bpd brother.. I wish him and his family good luck!

1. I am wholly in agreement with you, as I believe is the writer of the emails to me, H.O., that those who live with a BPD sufferer pay a terrible price. This post is not meant in any way to minimize the costs to them.

2. The writer in this article, H.O., is a very special person who, in spite of her bpd, dedicates her life to helping others. And while she does suffer greatly from bpd, she is very clear that she is not the victim of others' actions but rather the victim of a hyper-reactive emotional system. Please, readers, do not engage in wrongful insinuations about her motives or character.

3. In my office suite my colleagues and I have been developing new ways to reduce emotional hyper-reactivity. Our initial results look extremely promising. A cure for bpd may well soon be available. I will be writing more about these new techniques in subsequent articles.

4. When bpd emotional hyper-sensitivity is combined with narcissism, paranoia, Aspergers, sadism, sociopathy, addictions, or other co-morbid disorders, which is common for bpd, you get extremely hurtful people.

In this regard I see the diagnosis of bpd needing to be re-clarified. Right now many people assume that the problems from these additional disorders are part and parcel of bpd. That has not been my experience. Some bpd folks have them, others clearly do not, suffering only from the core bpd disorder of emotional hyper-reactivity.

So in sum, while I totally agree with you that your brother sounds like he was a profoundly negative influence in your family and your growing up, the aspects of his functioning that made him so toxic may have come from multiple co-occuring disorders in addition to bpd.

I hope this response has been helpful. Thank you so much for sharing your important perspective.

Whenever I hear reports of the abusive behaviour committed by those with BPD I always ask was the person diagnosed with the condition. So often the response is "No because he doesn't think he has a problem but I know he has because I read the 9 criteria and they all apply to him." So many of these anecdotal accounts are not accurate and should not be taken at face value.

Since the birth of DBT there are now numerous treatment methodologies that enable full recovery from BPD. Schema Focussed Therapy is proving the most effective so far but there are many to choose from including Transference Focussed Therapy, Cognitive Anlytical Therapy, Mentalisation Based Therapy and the list goes on.

There is no need for new treatments to be created but there is a dire need for therapists and clincians to overcome their prejudice towards BPD patients and train in techniques that work.

When someone with BPD is treated with an inappropriate therapy it makes them ill and causes terrible problems with counter transference when the therapist becomes frustrated with the patient for not responding well to treatment.

BPD needs to be retrieved from this septic contamination with discussion of other disorders. BPD is BPD is BPD. Many people with NPD are wrongly diagnosed with BPD by prejudiced professionals or simply because they are women.

One can easily be both the victim of a hyper-reactive emotional system and a victim of others' actions at the same time. Often, the two go hand in hand and one is a product of the other. H.O. does not ignore this fact, as she does mention suffering abuse as a child (unless you'd like to argue she brought the abuse on herself?). Often, a childhood environment in which naturally intense emotions are invalidated just makes the emotions bigger and more painful and creates problems later on. I suffered relentless bullying all throughout grade school BECAUSE of my hyper-reactive emotional system--people would intentionally say stuff to flip me out and then stand by and watch the "fireworks" go off, sometimes when I actually had a panic attack and couldn't stop hyperventilating. Imaginary pop quizzes, imaginary cockroach sightings (I'm terrified of them)... one kid actually told me my little sister was injured, just so everyone could watch me "go off" for the sake of entertainment. I remember immediately running to the nurse's office and upon finding out that I had been lied to, sobbing profusely in there for 2 hours and missing the rest of my classes that day. I had no idea, at that time, how over-the-top and sometimes inappropriate (and apparently hilarious for everyone else) my reactions were, just that I couldn't control them. That was my part of it. At the same time, what they did was, frankly, a lot like tripping someone with crutches. And that doesn't even BEGIN to touch onto what was happening at home.

Lots of people who have BPD dedicate their life to helping others--Marsha Linehan and Tami Green (whose materials I'd HIGHLY suggest you look at), for instance--but also countless teachers, nurses, scholars, etc. Speaking of dedicating lives to helping others: anyone suffering from mental illness who has seen multiple therapists and psychiatrists can tell you that, by and large, the most helpful mental health professionals are those who have previously suffered from mental illnesses, or currently suffer from personality disorders, themselves. I largely suspect that the reason DBT is so successful and has helped so many is because Linehan developed it knowing exactly what BPD individuals needed and weren't getting, because of her own experiences.

Understand that in terms of treating this disorder, no matter what amygdala-altering therapy you seem to be working on (obviously I'm not questioning the significance of amygdala size and activity in this disorder), your work will always be inferior to that of mental health professionals like these because you will never truly understand the disorder you aim to treat. The statement is even more true if you refuse to let go of your notion that everyone with BPD is somehow inferior. It's like when rich white girls with superiority complexes go on "voluntourism" trips in Nicaragua and don't speak spanish--those communities need people who speak their language and are willing to understand their experience and, while helping them in their current situation, do not see the Nicaraguans as "less than" themselves. BPD individuals need much the same thing--someone who speaks their language and does not see them as inferior, or "bad" people. We just need to feel like we deserve to live.

I'd love to see what Linehan would have to say regarding your previous articles. I don't imagine she'd be very impressed.

Hurt begets hurt. No matter how much pain someone is in from living with a borderline individual, it is nothing compared to the pain felt by the borderline individual themselves. This is because the non-borderline individual can easily find support and sympathy for their pain, while, conversely, the borderline individual is always "the bad one who needs to go away" and continuously shamed for their pain.

Anyway, that's my two cents. I have to finish writing my dissertation on watershed assessment in urban communities, if I can manage to not ruin any more lives along the way.

"No matter how much pain someone is in from living with a borderline individual, it is nothing compared to the pain felt by the borderline individual themselves."

I'm not sure how you can compare a BPD's pain with a non BPD's pain and I find it kind of arrogant to do so. This is a common pattern I've noticed with individuals with BPD, they hold their own feelings to such a high degree of importance that all else is eclipsed. I don't think we can compare one another's pain, or should even try, but I do think we can be accountable for our own.
Many people experience large amounts of suffering and they don't display the kind of manipulative (i believe BPD's display manipulative behavior whether it is a result of desperation or not, the two are not mutually exclusive) and hurtful behaviors that BPD's often resort to. I understand they are in pain and desperate to get their needs met but I believe it is because of their emotional immaturity and lack of coping skills that they know of no other way to communicate how they feel or get those needs met without being manipulative. I agree that we should avoid using disparaging words such as evil or sadistic, have compassion for people who are suffering but we also need to build up a sense of responsibility in those who tend towards self-victimization.

The commenter with BPD's descriptions of BPD perceptions and behaviors illustrates very clearly why and how the children of BPD parents are at very high risk for emotional abuse, emotional neglect, physical abuse, physical neglect and trauma.

"No matter how much pain someone is in from living with a borderline individual, it is nothing compared to the pain felt by the borderline individual themselves."
I'm not sure how you can compare a BPD's pain with a non BPD's pain and I find it kind of arrogant to do so. This is a common pattern I've noticed with individuals with BPD, they hold their own feelings to such a high degree of importance that all else is eclipsed. I don't think we can compare one another's pain, or should even try, but I do think we can be accountable for our own.
Many people experience large amounts of suffering and they don't display the kind of manipulative (i believe BPD's display manipulative behavior whether it is a result of desperation or not, the two are not mutually exclusive) and hurtful behaviors that BPD's often resort to. I understand they are in pain and desperate to get their needs met but I believe it is because of their emotional immaturity and lack of coping skills that they know of no other way to communicate how they feel or get those needs met without being manipulative. I agree that we should avoid using disparaging words such as evil or sadistic, have compassion for people who are suffering but we also need to build up a sense of responsibility in those who tend towards self-victimization.

Totally agree with this comment. I am not a BDP sufferer, however i am am on the receiving end of such treatment. If people with BDP are so contentious about their suffering then they should also have the capacity to comprehend how their actions are affecting other people, since they are so in touch with how everything makes them feel. Alas this seems like a rare occurrence as the behaviour is justified by their feelings.

I cannot imagine how some with BPD feels and i never will because no one can truly know how another person feels. And i do believe that they may feel like they are in hell and i would like to do things to help. However they cant seem to ever understand that living with them feels just the same, hell on earth! Nothing ever seems enough for these people as their negativity just seems perpetual and they don't realise that it's them not everyone else, yet they continue to place the responsibility to resolve their problems on other people.

People with BPD should start communicating so that others can help them and also understand what they are going through, More importantly understand the result of their behaviour. I don't care what you have but making someone feel as bad as you do is completely unacceptable behaviour full stop, no buts, no because, as is screaming and raging.

I do believe in living your life through principles and treating other people as you would like to be treated and not ruling and treating people badly because of your feelings. I don't understand how people with BPD cant seem to do this.

"...they cant seem to ever understand that living with them feels just the same, hell on earth!"

"...they don't realise that it's them not everyone else, yet they continue to place the responsibility to resolve their problems on other people."

"...I don't understand how people with BPD cant seem to do this."

It's because they have a disorder. That's the whole point. Their bodies, their minds, their brain chemistry, is thwarting the process. That's why they're called "people with BPD."

That's why severely autistic people don't "get" being nice and making small talk.

That's why people with diabetes don't "get" insulin regulation.

That's why people with psoriasis don't "get" turning down their immune response.

Going back to the cancer-patient analogy, you would never say, "I don't understand why people with cancer can't just make their cells not mutate. Yes, I believe it's causing them pain and I'm sorry about that, but what they don't seem to realize or care about is that it's making everyone else miserable, too!"

The problem is that you don't seem to view BPD as a legitimate physiological problem, but as a matter of willpower and playing along on the part of the sufferer, and so of course, nothing they say will strike you as valid.

This is the problem with most mental illnesses: even educated people, and even educated people who claim to believe that mental illness is biological illness, often don't really "buy" that people suffering from mental illness are doing all they can to fall in line and act normal. They're just... I don't know - getting attention? Being difficult because it's fun?

I know this is an old comment but I just wanted to say thank you, Casey.

I was diagnosed with BPD in my early 20's after knowing something was "wrong" with me for most of my life. I was also bullied all through grade school and all the memories I have of that time are pretty cloudy. Your comment made me understand what actually went on during that period of my life and I just wanted to thank you for that

As a side note, all that bullying forced me into academia (because I had no friends) and I worked really hard at school to become someone that helped others, because I recognised that was what a "good" person did. I am now a professional in the medical field. I feel like this work has actually helped to calm my emotions a lot and has increased my communication abilities hugely. I also have good friends now, too.

When I first got diagnosed, I didn't think I could ever get better, that I couldn't change, that I was an "evil" person. I read these comments on these forums back then and that reinforced my feelings of helplessness and depression.

But I have gotten better with persistence and a lot of therapy. Its been a really long, slow journey with a lot of work. I still struggle sometimes but I want people who have this problem to know that YOU CAN GET BETTER. I know it can seem hopeless but you need to keep trying and you will get there. I realise I am not a bad person. It was my behaviour that was bad, not ME.

I used to suffer from BPD and am now pronounced "cured". H.O> is describing an accurate portrait of BPD and how we are treated by psychology today articles and especially the comments.
It is extremely painful!!

Quite frankly I have shook my head in disbelief in many of your other articles that present BPD in a preparative way. (even calling them Bad seeds and evil others try to portray them as psychopaths and serial killers on PT it is a distorted view of BPD) The commentaries write volumes about how awful it is to be forced to live with a BPD but no one seems to show compassion for the sufferers of BPD and no one acknowledges how incredibly painful it is to suffer from the disorder.

Thank you for reaching out to address this and for helping to show this hyper-reactive emotional system disorder clearer for what it is bot by blaming the victim of the disorder. and if you suffer from BPD you are clearly a victim of the disorder because it is a very painful disorder.
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I wish there could be more articles like this so that the families and supposed "normal" people could develop a greater understanding and compassion for what it is like to suffer from the disorder.

Yes, I am hoping that my own forward movement in understanding, thanks to H.O., the ravages of bpd for the sufferer will parallel similar movement in the therapy world toward more understanding, and ultimately to a cure. I am optimistic.... Stay tuned for the rest of the articles in this series!

If fact there are several! Many people have now fully recovered from the condition. Why are you still looking for a treatment when there are plenty out there? Train to deliver Schema Focussed Therapy and you can cure people with BPD. We want the treatment despite what people say about us, the problem is in finding therapists who are willing to train.

H.O. says that most of the treatments out there now help people with bpd to cope more effectively with their hyper-responsive amygdala. We are looking to calm the amygdala so it functions more normally.

I'm usually highly skeptical of apologies that are framed "I apologize if..." and "not my intent." You can't apologize for things you didn't do or for someone's perception of your actions. You can apologize THAT you did something, regardless of intent, that caused offense. I find the "I'm sorry if" phrasing is passive-agressive and very common among therapists as away to try to seem apologetic but limit liability and take little ownership. I do however appreciate your willingness to learn and change in regards to your email exchange.

I like your idea that "I'm sorry that..." is more potent in apologies than "I'm sorry if..." I'm not sure if you are right, but I think so.

For me the main thing I listen for in an apology is whether it is going to lead to learning and change. I very much appreciate your having noted that aspect of my response to the initial critical email. Thanks for commenting on that!

I truly hope that you and your colleagues can develop more effective therapies for treating borderline pd, as an adjunct to dialectical behavioral therapy which currently seems to have the best track record with improved outcome for bpd patients. A lot of the research papers I've been finding seem to agree that multiple areas of the brain are not functioning properly in those with bpd, particularly the amygdala area and the executive function area of the brain, so a multi-disciplinary approach to treatment of a disorder which is at least partly organic and genetic in nature would seem to be the logical course of action.

And I'm glad that H.O. wrote what it feels like to have bpd, and that you shared your correspondence with us here. The emotional pain she has experienced is all too heartbreakingly real and severe and seems to be all too freqent in those with borderline pd, although from what I've read, there also seems to be a spectrum of severity of the disorder.

I have to say that H.O.'s description of what it feels like to have bpd corroborates my experiences RE having been raised by a mother with borderline pd. I frequently witnessed my mother's emotional pain and experienced the dysfunctional ways she dealt with it.

If a person is feeling frequent and intense mood swings causing severe levels of emotional pain; if a person is engaging in self-harming or suicidal behaviors often, or is often engaging in blaming, or is helplessly triggered into raging behaviors as the result of or in an attempt to cope with the emotional pain, then clearly that individual is not healthy enough to be raising children alone and/or unsupervised.

A child is highly vulnerable to being traumatized by such behaviors coming from their mother or father, and highly vulnerable to having their own normal emotional development derailed by an emotionally dysregulated, unstable, highly impulsive, erratic, unpredictable primary caregiver.

No child is able to cope in a healthy way with a mother who may act loving towards her child one moment, then become hysterical or enraged at the child the next moment, may perhaps leave her small child alone for half a day to impulsively go to an entertainment event with friends, or perhaps drive erratically (rage driving) with her child in the car, or may begin cutting herself in front of her child, or threaten to shoot herself, or other impulsive, self-destructive or other-destructive behaviors in the presence of her terrified, bewildered child.

This is my main point:

Yes, those with borderline pd need help, and empathy and support, and intensive therapy, but their children also need help, empathy and support to the same degree of urgency, if not moreso.

Empathy is, or should be, a two-way street.

My best wishes to you and everyone who is determined to develop more effective treatments for bpd; here's hoping you succeed sooner rather than later.

@Annie, your comment crystallized for me that treatment for bpd needs to combine therapies that that eliminate the biological dysfunctions and that build the skills for healthy day-to-functioning. As you wrote, bpd needs "a multi-disciplinary approach to treatment of a disorder which is at least partly organic and genetic in nature."

I am delighted to report that we (Dale Petterson, the energy therapist in my office) and I seem to be closing in on a multi-disciplinary cure.

Biologically, we repair the amygdala so it reacts like a normal amygdala to end the emotional hyper-reactivity and raging. We rearrange energy distribution in the two pre-frontal lobes so that the distribution is characteristic of folks who are happy and not of people who are depressed. Believe it or not, these treatments together take less than an hour and require no medication or invasive procedures.

We clean out negative energies from prior hurtful experiences via a speeded-up version of psychodynamic work called Emotion Code (created by Bradley Nelson).

Third, we expand practical living skills with dbf-type skills for individual functioning and with teaching collaborative dialogue and win-win-conflict resolution skills so both intra-psychic and interpersonal interactions both flow more smoothly.

Sound unbelievable? We are working now on video-taping what we do. Our research team, which also includes H.O. who is a physician and another bpd sufferer who is a nurse, is making the videos and preparing them to put up on YouTube over the next few months.

I'm hoping someone with research capacity will then take these methods to the next step which would be large-scale double-blind or equivalently scientific testing.

I share you concerns for the children who suffer from bpd parents. That's part of what gives me a strong sense of urgency to get our new treatment methods consolidated and tested, train professionals who can do them, and get the word out, all asap.

If your multidisciplinary theraputic approach to BPD works and demonstrates valid and reliable positive results across multiple clinical trials (and the results hold; you'll need followup studies as well) you will have done a great service for humankind.

My best wishes and emotional support go to you! I look forward to seeing your YouTube documentaries.

I am very interested to hear more about your work repairing the amygdala. I have been studying the way the amygdala handles fear and how this effects attachment disorders. Very interested for any more information you might have on this.

I have been preparing a youtube video of the work of Dale Petterson, an energy therapist. My plan is to post a PT article with a link to it once it's ready. The goal of the video is to interest researchers in following up.

Are you associated with a lab that can study the amygdala changes that seem to occur with this treatment? That's what I'd love to find.

Another of my associates uses Body Talk, an Australian technique, to quiet the amygdala. She's been getting outstanding results. You can google Body Talk for more information on these techniques.

Thank you for helping people to understand Borderline Personality Disorder.Borderline Personality Disorder requires patience and an educated understanding since it's not a choice that one can make on whether to have it or not. Recovery from Borderline Personality Disorder requires rebuilding trust. Borderline patients must trust the people who are helping them. Their sense of security must return so that they can feel safe and the people who can really help them overcome these outcomes are there family members who love them enough to help them in their healing. The family members should be tolerant of their vulnerabilities. They must have the willingness to take care of them.

To adjust the amygdala we use similar techniques, asking first at what level, from 0 to 10, the responsivity of the amygdala is currently set, and then resetting it to a more optimal level. Most borderline folks reset from 8, 9 or 10 to about a 4, which is typical for "normal" people as well.

This reset is temporary. To teach the amygdala to stay at this calmer level, we teach temporal tapping (there's videos of this on youtube). As they tap people say "My amygdala is set at 4." They repeat the tapping 3 to 4 times a day until it seems to stay without the repeated tapping reprograming.

I am currently in a relationship with a man with BPD. I am so angered by what I am reading here that the person with the BPD only needs love, love and more love! This personality type is the most unlovable personality I have ever known. My father was a BPD, alcoholic; beat his wife and children and ruined the lives of his children. I will never forgive him. Maybe I need therapy for this, maybe if his family had just given him more "love and understanding.
Give me a fuckin break.

The reason that bpd people feel so love-starved is that they act in ways that are incompatible with people loving them. Would you pet a gnarling dog? Hopefully not. And if the dog bites people, you would, hopefully, remove the dog from your life-space.

The point of this article is to understand more compassionately what people with bpd experience. At the same time both H.O. and I would advise that self-protection has to be a first consideration. Compassion from afar is one thing. Staying close to someone who acts in a manner that is emotionally or physically harmful to others is a big mistake.

Also, I/we agree that bpd is not just a matter of a family not having given enough "love and understanding." It results, we think, from a mix of genetic predisposition and childhood trauma, plus insufficient anger management strategies. Toss in additional bad habits such as alcoholism and abusive behavior and you have someone like your father.

Your response is typical of someone who does not at all understand the disorder and shows serious ignorance.

This is a brilliant illustrative example of the stigma people with BPD face--essentially for feeling an amount of pain every minute of every day that feels like cancer. That very notion of being "unlovable" makes the pain ten times worse. Seriously, imagine if you woke up one morning and literally everyone you passed that day punched you in the stomach. Then, right before you went to sleep, someone leaned over your bed and said,"You should probably just die. We'd all appreciate it". That's what BPD feels like. Many people with BPD are NOT abusive. Yet, the actions of a few allow the general public to assume anyone with a substance abuse or anger problem is automatically BPD, which is not only inaccurate but exacerbates the stigma problem.

Was your father/boyfriend ever officially diagnosed? My guess is not. Men who abuse and are alcoholics can have any number of personality disoders besides BPD--depresssion, antisocial PD, bipolar PD, etc. The likelihood of you knowing two different MEN with BPD is extremely unlikely, as 75% of cases are women. Unless you're a psychiatrist, I'm guessing you just sort of decided anyone difficult in your life has the disorder, like so many other ignorant people.

Many of those diagnosed with the disorder have histories of parents abusing or neglecting them as children. Their emotional needs are not met during childhood so they are overly emotional as adults. As a survivor of child abuse, you show a shocking lack of compassion. If your current boyfriend actually does have BPD, you guys should break up. No one deserves to be in a relationship with someone who believes they are "unlovable".

Below are the links to articles referring to a large, long-term study of those with borderline pd; the study concludes that there is no gender difference in prevalence of borderline pd between males and females; both men and women have borderline pd at about the same rate or percentage.

The misperception that borderline pd is overwhelmingly a "women's disorder" was caused by sampling bias: men and women with bpd tend to utilize different treatment protocols, so they were counted in different sets of statistics.

Men with bpd tend to wind up in substance abuse programs or incarcerated, while women with bpd tend to wind up in psychiatric care, as in-patients or out-patients.

My sense is that in addition to being give different treatments, borderline men have been given different diagnoses, e.g., abusive, psychopathic or intermittent explosive disorder instead of borderline.

Thanks for this article - it's always good to see a therapist gain a more empathic view toward those with early trauma.

As I have noted in other articles on this site, I'm a former borderline who has recovered to live a very functional and good life. After once having all 9 borderline symptoms, I have been free of all of them for the last few years. My account of how I made this progress is on my site at bpdtransformation (dot) wordpress (dot) com .
If you are interested in an unconventional perspective on BPD and how to recover from it, I encourage you to take a look.

I am SHOCKED you'd actually post this. The articles you've written about BPD are misinformed at best. I read one article you wrote and you actually stated you could tell the moment a little girl walked into the room you could tell she had BPD! You have NO business discussing this topic as it is not your specialty and YOU are part of the problem in keeping people in the dark regarding mental health. Your articles regarding BPD aid in securing the "Us vs. Them" attitudes between BP's and non-BP's.

I am on the side of helping people with bpd. This kind of quick-to-make-unfounded-acusations reads like a bpd reaction.

Emotional hyper-reactivity gets people with bpd in trouble because
it typically is based on inaccurate understandings of what has been said and because it antagonizes recipients instead of launching cooperative dialogue.

You seem to have nothing but empathy for the posters here who leave scathing angry posts about how awful their life is living with a bpd. (and yet you have no real idea if their views are accurate or delusional in any way).

But when a poster here who has BPD tries to tell you you aren't accurately portraying their pathology and they feel misunderstood. You criticize how they tell you their feelings ... example above you accuse the BPD writer of "quick-to-make-unfounded-acusations" i.e. you are passively aggressively putting her down and not validating her. This actually is like rubbing salt on a wound of a BPD.

Yet you didn't feel the need to question the integrity of the person that wrote : "I am so angered by what I am reading here that the person with the BPD only needs love, love and more love! This personality type is the most unlovable personality I have ever known. My father was a BPD, alcoholic; beat his wife and children and ruined the lives of his children. I will never forgive him. "

That writer clearly has some over generalizations and pathological ideas that don't hold true i.e. they have no empathy at all yet you don't feel the need to chastise them like you do the BPD posters.

This is an example that you asked for about why BPDs think you are preparative to them. You are able to have unlimited empathy for the pathos of the angry family member of BPD but not have empathy for the actual BPD sufferer unless they write or word their feelings in a way that doesn't offend you. You don't seem to care that the family member comments are incredibly offensive to BPD Sufferers.

Does this make sense? I am not trying to put you down, I am trying to show you why BPD's don't feel you truly understand BPD.

"I read one article you wrote and you actually stated you could tell the moment a little girl walked into the room you could tell she had BPD!"

This sentence was the "quick-to-make-unfounded-generalizations" sentence I was referring to. It is an inaccurate interpretation of the article, not something that I said.

At the same time I very much appreciate your attempt to dialogue with me on a topic that is very important: how people who live with a loved one with bpd can sustain empathy for the sufferer of intense emotional hyper-responsivity and at the same time protect themselves.

Please note also that I have no intention "to chastise them [people with bpd] like you do the BPD posters." The fine line between offering clarifying feedback and chastising someone is sometimes hard to walk. Staying on that line offers a difficult challenge both for the person offering feedback and for the person receiving the feedback, to give and to receive information without slipping into or hearing information as criticism.

IN that regard, this sentence that you write is a partially true one:

"You are able to have unlimited empathy for the pathos of the angry family member of BPD but not have empathy for the actual BPD sufferer unless they write or word their feelings in a way that doesn't offend you."

This is a hard concept for bpd people sometimes to understand, that the rules of civility are rules that enable people to listen to one another and thereby pool their ideas and perspectives.

When someone with bpd, or anyone for that matter, speaks in emotional angry tones and with accusatory You-messages , the receiver's ears will tend to close. When by contrast they speak in I-language and calmer emotional tones, others listen.

Thank you for hanging in here to try to work together with me to clarify these tough questions

life with borderline personality disorder is HELL ON EARTH. i am well aware of how truly horrific my behaviour has been - esp during my early 20's when i totally unraveled. BUT, i also know the extreme childhood abuse and repeated abandonment i grew up with would leave ANYBODY as damaged as i turned out to be.

just an example: i grew up in several fosterhomes. during my 20's, one of my fostersisters was roofied and raped ONCE. this incident left her completely helpless for A YEAR. she had to move back in with her rich parents, who paid her bills, got her the best treatment possible all while sympathizing deeply with her.

now me, i experienced sexual and physical abuse DAILY from the day i was born. i was left by first my mother as a 1 year old, then my grandma who left me with some horrid people who treated me like shit, and then sent to another country to live my dad - a violent and volatile person who damaged me *repeteadly* so bad i ended up with surgery again and again and then group home, foster home and finally a life as a homeless drugaddict with severe borderline personality disorder (this is the short and sanitized version so as not to shock y'all how truly HORRIFIC some people grow up).

i have never known what it means to feel safe or loved. i've been treated as shit and thought i was meant to be treated as shit well into my 30's.

i do not for one second mean anybody should've had to put up with my rage, insane jealousy and other desperate behaviours i used to display in my 20's when retraumatized. BUT i would appreciate recognition for the hell most of us with bpd grew up with. we didnt have the opportunity to develop healthy brain functions. and i dare anybody to say they would've turned out that much better after a childhood of repeated trauma and abuse with not one single person validating our experience.

why do "normal" people have all kinds of understanding for the damage done to an adult going through a single trauma experience, like my fostersister went through, but not developmental trauma, relational trauma and childhood- serial trauma which is opbviously that much worse?

Borderline personality disorder is a heritable brain disease
Current Psychiatry 2014 April;13(4):19-20, 32.
Henry A. Nasrallah, MD
Editor-in-Chief
The prevailing view among many psy­chiatrists and mental health profession­als is that borderline personality disorder (BPD) is a “psychological” condition. BPD often is conceptualized as a behav­ioral consequence of childhood trauma; treatment approaches have emphasized intensive psychotherapeutic modali­ties, less so biologic interventions. You might not be aware that a large body of research over the past decade provides strong evidence that BPD is a neuro­biological illness—a finding that would drastically alter how the disorder should be conceptualized and managed.
Neuropathology underpins the personality disorder
Foremost, BPD must be regarded as a serious, disabling brain disorder, not simply an aberration of personality. In DSM-5, symptoms of BPD are listed as: feelings of abandonment; unstable and intense interpersonal relationships; un­stable sense of self; impulsivity; suicidal or self-mutilating behavior; affective in­stability (dysphoria, irritability, anxiety); chronic feelings of emptiness; intense anger episodes; and transient paranoid or dissociative symptoms. Clearly, these clusters of psychopathological and be­havioral symptoms reflect a pervasive brain disorder associated with abnormal neurobiology and neural circuitry that might, at times, stubbornly defy thera­peutic intervention.
No wonder that 42 published stud­ies report that, compared with healthy controls, people who have BPD display extensive cortical and subcortical abnor­malities in brain structure and function.1 These anomalous patterns have been detected across all 4 available neuroim­aging techniques.

Magnetic resonance imaging. MRI studies have revealed the following abnormalities in BPD:
• hypoplasia of the hippocampus, caudate, and dorsolateral prefrontal cortex
• variations in the CA1 region of the hippocampus and subiculum
• smaller-than-normal orbitofrontal cortex (by 24%, compared with healthy controls) and the mid-temporal and left cingulate gyrii (by 26%)
• larger-than-normal volume of the right inferior parietal cortex and the right parahippocampal gyrus
• loss of gray matter in the frontal, temporal, and parietal cortices
• an enlarged third cerebral ventricle
• in women, reduced size of the me­dial temporal lobe and amygdala
• in men, a decreased concentra­tion of gray matter in the anterior cingulate
• reversal of normal right-greater-than-left asymmetry of the orbitofron­tal cortex gray matter, reflecting loss of gray matter on the right side
• a lower concentration of gray mat­ter in the rostral/subgenual anterior cin­gulate cortex
• a smaller frontal lobe.
In an analysis of MRI studies,2 cor­relation was found between structural brain abnormalities and specific symp­toms of BPD, such as impulsivity, sui­cidality, and aggression. These findings might someday guide personalized in­terventions—for example, using neuro­stimulation techniques such as repetitive transcranial magnetic stimulation and deep brain stimulation—to modulate the activity of a given region of the brain (depending on which symptom is most prominent or disabling).

Magnetic resonance spectroscopy. In BPD, MRS studies reveal:
• compared with controls, a higher glutamate level in the anterior cingulate cortex
• reduced levels of N-acetyl aspar­tate (NAA; found in neurons) and cre­atinine in the left amygdala
• a reduction (on average, 19%) in the NAA concentration in the dorsolat­eral prefrontal cortex.
Functional magnetic resonance im­aging. From fMRI studies, there is evi­dence in BPD of:
• greater activation of the amygdala and prolonged return to baseline
• increased functional connectiv­ity in the left frontopolar cortex and left insula
• decreased connectivity in the left cuneus and left inferior parietal and the right middle temporal lobes
• marked frontal hypometabolism
• hypermetabolism in the motor cor­tex, medial and anterior cingulate, and occipital and temporal poles
• lower connectivity between the amygdala during a neutral stimulus
• higher connectivity between the amygdala during fear stimulus
• higher connectivity between the amygdala during fear stimulus
• deactivation of the opioid system in the left nucleus accumbens, hypothal­amus, and hippocampus
• hyperactivation of the left medial prefrontal cortex during social exclusion
• more mistakes made in differenti­ating an emotional and a neutral facial expression.

Diffusion tensor imaging. DTI white-matter integrity studies of BPD show:
• a bilateral decrease in fractional an­isotropy (FA) in frontal, uncinated, and occipitalfrontal fasciculi
• a decrease in FA in the genu and rostrum of the corpus callosum
• a decrease in inter-hemispheric connectivity between right and left ante­rior cigulate cortices.
Genetic Studies
There is substantial scientific evidence that BPD is highly heritable—a finding that suggests that brain abnormalities of this disorder are a consequence of genes involved in brain development (similar to what is known about schizophrenia, bipolar disorder, and autism).
A systematic review of the heritabil­ity of BPD examined 59 published stud­ies that were categorized into 12 family studies, 18 twin studies, 24 association studies, and 5 gene-environment inter­action studies.3 The authors concluded that BPD has a strong genetic compo­nent, although there also is evidence of gene-environment (G.E) interactions (ie, how nature and nurture influence each other).
The G.E interaction model appears to be consistent with the theory that ex­pression of plasticity genes is modified by childhood experiences and environ­ment, such as physical or sexual abuse. Some studies have found evidence of hypermethylation in BPD, which can ex­ert epigenetic effects. Childhood abuse might, therefore, disrupt certain neuro­plasticity genes, culminating in morpho­logical, neurochemical, metabolic, and white-matter aberrations—leading to pathological behavioral patterns identi­fied as BPD.

The neuropsychiatric basis of BPD must guide treatment
There is no such thing as a purely psycho­logical disorder: Invariably, it is an abnor­mality of brain circuits that disrupts normal development of emotions, thought, behavior, and social cognition. BPD is an exemplar of such neuropsychiatric illness, and treat­ment should support psychotherapeutic ap­proaches to mend the mind at the same time it moves aggressively to repair the brain.

Warmest thanks for sending this compilation of research findings on brain changes in bpd.

I am especially interested in the findings from the MRS with regard to amygdala difficulties as they corroborate our treatment findings:

In our offices we use two different energy therapy interventions to address the amygdala's role in excessive emotional hyper-reactivity. Both have been getting excellent results, i.e., calmer overall feelings states, negative emotions that do occur become of lowered intensity, and these states calm far more easily.

It seems that stigma for certain mental health conditions is alive and well, even in this day and age.

From what I've read it seems that the writer of these articles has very little to any true understanding of what it's like to live with something like BPD and if that's really the case then the writer should respectfully refrain from writing articles on the condition especially if it paints these people to be the bad guys and perhaps educate herself a little more.

The only people who truly qualified to say anything about BPD are those who have it, their closet family members and friends and those professionals who have actually done extensive studies and specialise in BPD and/or Personality Disorders in general.

Dr Heitler, thank you for such an in-depth, sympathetic article (and for your insightful responses to comments). I was just recently diagnosed with BPD and it was a relief! I have to say that I always know what I am doing, but can't stop. There have been times when upset that I could literally SEE myself arguing maliciously or screaming, like I was hovering above myself. At these times, the "real me" is trapped right there, invisible, mute, desperate, horrified and ashamed and begging myself to stop.

I can't imagine how hard it must be for those with BPD that can't admit they have it. Admitting makes it easier. It also makes it easier for that good-intentioned person stuck inside me at those horrid panicky points to know that she has strength, too. The lowest points--often suicidal--come after I've had an outburst, when I feel that I might be trapped inside myself forever, this unpleasant, spoiled, angry-for-no-reason, wasted-potential adult in her mid-30s. I want so desperately to be only the loving sister, daughter, friend, medical professional that I have struggled so hard to be the last ten years.

To those people who are in relationships or have been hurt by BPD, I am sorry for you. You will not be able to be the "therapist" a BPD sufferer obviously needs. The best advice I can give is (though I know it's nearly impossible to apply when it's your mother or husband or child): DON'T TAKE IT PERSONALLY. If you look closer you will see the BPD sufferer trembling helplessly with the weight of a beast on their back.

I forgot to elaborate--admitting I have BPD makes it easier to accept responsibility for my behavior! It also makes it much easier to focus on a problem, a goal, and a solution. BPD sufferers often struggle with identity, and I have. Just being given the diagnosis was such a relief to me; it was actually empowering. I can now take responsibility for a solution.

I found this exchange to be very enlightening. H.O. is right. We do stigmatize those that we don't really understand. I can believe that most are desperate and want someone to understand and help them. It honestly was a shock when she compared BPD to cancer. I personally don't know anyone who has BPD, but the way she describes that pain that people go through was astonishing. When reading on it, I have never seen it put in such a descriptive way as H.Om does.

Finally, some truth about what it is like to suffer with BPD. Actually, tonight I was contemplating trying once again to end my life, since I know what I am--a diagnosed borderline.

If you Google borderline you can read all sorts of nice things about yourself (as if you didn't already hate yourself enough). It reaffirms that I am not welcome on this earth and not worthy of life or love (or even 'like' for that matter).

The mental health "professionals" who add to our stigma and suffering do not help matters (especially Randy Kreger--who sufferers of BPD find quite repulsive).

I've been asking myself-- why go on? It seems like the entire world hates who I am--what I am--and what I am is "difficult" and bad and horrible. Something that therapists don't even want to work with. Pretty much the worst of the worst.

I've been abused since I was born and then stupidly married a man who abused me, and then when my son was old enough, BPD as he also is, abuses me. I sat here tonight amongst a mountain of prescription drugs and decided to put off killing myself, just one more day.

But the pain is unbearable. It is like being burned alive, with no emotional "skin". Hell. On. Earth. I've often thought that maybe if I could get an amygdalectomy, maybe it would stop the pain. If it would stop the pain, I'd get a lobotomy.

Nobody wants to feel like this. To be like this. We didn't ask to be born. We just plod along through our suffering--I have begged god countless times to give me cancer and just let me die naturally, so no one would have to suffer from my suicide.

At the same time, there is hope. I am so glad to read that you are living on because there is hope for you. Your pain can be relieved.

Have you tried working with a therapist who specializes in DBT (dialectical behavior therapy) treatment for borderline dysfunction? Studies have suggested that for clients who are motivated to learn and grow, the mindfulness and other techniques taught in this program can prove very helpful.

In addition, I would suggest two newer treatments. Acupoint tapping, also called Emotional Freedom Technique or EFT (but not to be confused with the EFT that stands for Emotionally Focused Therapy), rapidly reduces painful feelings. It is probably the very best treatment for ptsd. Given the trauma you have suffered in your life, the tapping could quite possibly offer significant relief. To find a practicioner where you life, try doing a google search.

In our office suite my colleagues and I also do a new experimental technique that quickly reduces amygdala sensitivity. It takes just a few minutes, needs follow up with mutliple times per day of temporal tapping (see my youtube video on temporal tapping), but does seem to enable people with bpd to feel calm and well-being.

If you go to my clinical website, therapyhelp.com, you can contact me directly for more information. Use the Contact Us form.

Bravo on writing instead of ending your life. There really is hope for you and for the many others like you who suffer so intensely.

I was diagnosed with BPD after several failed suicide attempts. Received no counselling or therapy and begged for it for years, grew up in hell. Most other Borderlines I met online were exactly as you describe and when attempting to discuss this online was bombarded with slander and hatred and defensiveness, which hurt. But both both myself and the others are too narcissistic to do anything about it in terms of resolution. I realised I hate other Borderlines, they are the worst, most annoying, self centred people ever and I hate myself for being inclusive of that disorder and being one of them. Coming to terms with what I am is comparable to a bereavement. The other Borderlines said I was just projecting how I felt about myself onto them when none of that was applicable to them (narcissistic injury in other words). But in reality, it was seeing nasty Borderlines and coming into contact with them online, in hospital, in other ways, which opened up my eyes to some of my own behaviours. I gave up trying to get help. Was abused my whole life, am now just drifting along and don't care about anything. I live in England by the way. Over here even the 'professionals' treat Borderlines like filth, goad and antagonise them... As long as I'm not homeless on the street I don't care what happens to me.

That's truly unfortunate that the newer therapies like DBT (that are showing good success rates) aren't being utilized by more psychiatrists and psychologists in the UK, but there is hope for you via self-help.

The fact that you understand and accept that you have this disorder, and the fact that you WANT to go into therapy to learn how to overcome it, means that there is a really high probability that you CAN recover from it or at the very least achieve significant improvement; half your battle is won already.

Below is the link to a website that describes Dialectical Behavioral Therapy, and it links to self-help mp3s that you can access.

You can Google "DBT self-help online" and find other resources; some of these DBT self-help websites are free, and others offer online therapy with a trained therapist for a fee, but I just wanted to give you some hope; even if you can't find a good in-person therapist in your area, there are resources on-line that you can check out.